Comparative Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement According to Body Mass Index: A Meta-Analysis of Randomized Controlled Trials

Whether body mass index (BMI) modifies the comparative outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) remains uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials comparing TAVR and SAVR. The primary endpoint was a mortality-inclusive composite outcome. Analyses were stratified by trial-reported BMI categories, primarily non-obese versus obese, and by surgical risk (low vs intermediate–high). Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using random-effects models, with evidence certainty assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Seven trials comprising 8,437 patients were included. TAVR significantly reduced the primary endpoint versus SAVR in both non-obese patients (RR, 0.74; 95% CI, 0.56–0.96; P = 0.02; I 2 = 22%; high certainty) and obese patients (RR, 0.70; 95% CI, 0.51–0.96; P = 0.03; I 2 = 0%; high certainty), with no evidence of effect modification by obesity status ( P for interaction = 0.81). Using a BMI cutoff of 25 kg/m 2 , TAVR and SAVR did not differ significantly in normal-weight patients (RR, 0.79; 95% CI, 0.55–1.14; P = 0.21; I 2 = 66%; low certainty) or overweight/obese patients (RR, 0.83; 95% CI, 0.61–1.13; P = 0.25; I 2 = 58%; low certainty), with no subgroup interaction ( P for interaction = 0.83). Stratification by surgical risk showed a significant benefit of TAVR in low-risk non-obese patients (RR, 0.57; 95% CI, 0.38–0.83; P = 0.004; I 2 = 0%; high certainty), with no significant interaction between surgical risk and treatment effect in either non-obese or obese patients. TAVR was associated with better clinical outcomes than SAVR in both non-obese and obese patients, with no evidence that obesity modified treatment effect. Stratification by surgical risk suggested a greater benefit of TAVR in low-risk patients, particularly among non-obese individuals.